61 terms

Burns & Wound Care

STUDY
PLAY
When assessing a patient suffering from inhalation burns on the face and chest, what findings should a nurse anticipate? Select all that apply.
Correct 1
Increasing hoarseness
2 - Location of contact points
3 - Leathery white charred skin
Correct 4
Darkened oral or nasal membranes
Correct 5
Productive cough with black sputum
In inhalation burns, either the respiratory tract is exposed to intense fumes or heat, or the patient inhales noxious chemicals or smoke. Increasing hoarseness is seen due to irritation of the upper airway during inhalation and the laryngeal edema caused by inhalation injury. Some other signs include darkened oral or nasal membranes and productive cough with black sputum, which are evident due to charring of the membranes of the respiratory tract. Location of contact points is done in case of electrical burns. In this case, the skin may appear leathery white and charred.
Text Reference - p. 456
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When teaching patients and caregivers about the strategies to reduce burn injuries, what essential instructions does the nurse give? Select all that apply.
1
Store chemicals in the lowest shelves to avoid mixing up with other household chemicals.
2 - Perform outdoor activities during lightning storms.
Correct 3
Ensure an electrical power source is shut off before beginning repairs.
Correct 4
Never leave burning candles unattended or near windows or curtains.
Correct 5
Check temperature of bath water with the back of hand or bath thermometer.
Ensure that the electrical power source is shut off before beginning any repairs to avoid electrical burn injury. Never leave candles unattended or near open windows or curtains to avoid fire. Check the temperature of the bath water using the back of the hand or use the bath thermometer to avoid scalding burns, which commonly occur due to hot bathing water. Chemicals should be stored safely, preferably out of reach of children, in clearly written labels. Performing outdoor activities during lightning storms increases the risk of electrical injury from the ongoing lightning.
Text Reference - p. 451
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A patient is brought to the emergency department (ED) with severe burns on the legs and feet. Which factors lead the nurse to believe the patient may have full-thickness burns? Select all that apply.
Correct 1
Touch sensation is impaired.
2
Blanching with pressure is observed.
Correct 3
Lack of blanching with pressure is observed.
4
Wounds appear mottled white, pink to cherry-red.
Correct 5
Wounds appear waxy white, dark brown, or charred.
Touch sensation is impaired due to impaired nerve endings in full-thickness burns. Lack of blanching with pressure is observed, as all skin elements are destroyed. Wounds appear waxy white, dark brown, or charred in full-thickness burns, as all skin elements and local nerve endings are destroyed, and coagulation necrosis is present. Blanching with pressure is observed in partial-thickness burns because varying degrees of both the epidermis and dermis are involved, and skin elements of regeneration are viable. Wounds appear mottled white, pink to cherry-red in a partial-thickness burn.
Text Reference - p. 455
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The patient in the acute phase of burn care has electrical burns on the left side of the body, type 2 diabetes mellitus, and a serum glucose level of 485 mg/dL. What should be the nurse's priority intervention to prevent a life-threatening complication of hyperglycemia for this burned patient?
Incorrect1
Replace the blood lost
2
Maintain a neutral pH
Correct3
Maintain fluid balance
4
Replace serum potassium
This patient most likely is experiencing hyperosmolar hyperglycemic syndrome (HHS). HHS dehydrates a patient rapidly. Thus HHS combined with the massive fluid losses of a burn tremendously increases this patient's risk for hypovolemic shock and serious hypotension. This is clearly the nurse's priority because the nurse must keep up with the patient's fluid requirements to prevent circulatory collapse caused by low intravascular volume. There is no mention of blood loss. Fluid resuscitation will help to correct the pH and serum potassium abnormalities.
Text Reference - p. 457
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The nurse is attending to a patient who is recovering from a full-thickness burn. The nurse understands that the patient is in a hypermetabolic state and needs nutritional support to promote wound healing and prevent malnutrition. What types of food and drinks should the nurse provide to the patient? Select all that apply.
1
Tea
Correct 2
Milkshakes
Correct 3
Protein powder
4
Low-protein food
Correct 5
High-calorie food
A patient with burns needs a high-calorie diet to compensate for the energy loss and increased protein intake to avoid malnutrition and delayed healing. Milkshakes have high calories. Protein powder provides high protein. High-caloric food contains calories in large quantities and will help in the patient's recovery. Tea does not provide adequate quantities of calories and proteins. Low-protein food is not advised for a patient with burns, as the demand for proteins is high to promote healing and a faster recovery.
...
Which type of burn injury occurs on the layers of subcutaneous fat, muscle, or deeper structures?
1
Sunburn
Correct2
Full thickness burn
3
Deep partial thickness burn
4
Superficial partial thickness burn
A full thickness burn is a burn of the layers of subcutaneous fat, muscle, or deeper structures. A superficial partial thickness burn is a burn of the epidermis layer; a sunburn is a type of superficial partial thickness burn. A deep partial thickness burn involves the dermis layer, between the epidermis and subcutaneous layers.
Text Reference - p. 453
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When planning for burn management, which patients should the nurse refer to a burn center? Select all that apply.
Correct 1
Patients with hydrochloric acid burns
2
Patients of all ages with first-degree burns
Correct 3
Patients of all ages with third-degree burns
Correct 4
Patients with 25% deep partial-thickness burns
5
Patients with 5% superficial partial-thickness burns
Patients suffering from hydrochloric acid burns, also known as chemical burns, should be referred to a burn center. Patients of all ages with third-degree burns are severe in condition and should be treated in a burn center. All patients with partial-thickness burns more than 10% should be referred to a burn center, as they are severe types of burns and need specialized treatment, care, and isolation. Patients of all ages with first-degree burns can be managed in the hospital and assessed. Patients with 5% superficial partial-thickness burns need not necessarily be referred and can be managed in the hospital.
Text Reference - p. 453
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patient who sustained burn injuries is receiving daily treatments. He tells his caregiver, "The nurses enjoy hurting me." What should the nurse suspect? Choose the best answer.
1
This patient must be having hallucinations.
2
This patient might be having schizophrenia.
Incorrect3
This patient has a serious psychiatric condition.
Correct4
This is a normal reaction to an extraordinary life event.
Patients who have sustained burn injuries may experience a variety of emotions, including fear, anxiety, anger, guilt, and depression. The given example shows that the patient is angry and depressed, and it is important to reassure the patient and caregivers that these reactions may be normal and can be expected. The nurse should not assume from this reaction that the patient is experiencing hallucinations or any serious psychiatric conditions, including schizophrenia.
Text Reference - p. 469
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While treating a patient who is administered initial emergency burn care and is in the acute phase of burns, what actions should the nurse perform as a part of respiratory therapy? Select all that apply.
1
Avoid supplemental oxygen.
2
Prepare for discharge home.
Correct 3
Monitor for signs of complications.
Correct 4
Continue assessing oxygenation needs.
Correct 5
Continue to monitor respiratory status.
The nurse should monitor for signs of respiratory complications of burns to plan for appropriate respiratory therapy. Continue assessing oxygenation needs to plan for any alternations in oxygen supply. Continue to monitor the respiratory status to ensure proper breathing and circulation. Avoiding supplemental oxygen is not advisable, as oxygen needs may be assessed and started as required. Preparing for discharging the patient needs to be planned in the rehabilitation phase after the patient has recovered.

TEST-TAKING TIP: Work with a study group to create and take practice tests. Think of the kinds of questions you would ask if you were composing the test. Consider what would be a good question, what would be the right answer, and what would be other answers that would appear right but would in fact be incorrect.
Text Reference - p. 460
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The nurse is teaching strategies to reduce burn injuries to a group of new parents. Which comment, by a parent, indicates a need for further teaching?
1
"We will have fire exit drills once a month at home."
2
"I will not use gasoline in the fireplace when starting a fire."
Correct3
"I will make sure the hot water temperature is set at 140° F (60° C)."
4
"We will install hard-wired smoke detectors on each level of our home."
Hot water heaters set at 140° F (60° C) or higher are a burn hazard in the home; the temperature should be set at less than 120° F (40° C). A risk-reduction strategy for household fires is to encourage regular home fire exit drills. Gasoline or other flammable liquids should never be used to start a fire. Installation of smoke and carbon monoxide detectors can prevent inhalation injuries. Hard-wired smoke detectors do not require battery replacement; battery-operated smoke detectors may be used.
Text Reference - p. 451
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A patient has sustained thermal injuries amounting to approximately 30% of his total body surface area. What action should the nurse take first?
1
Cover the burned body area with ice.
2
Immerse the burned body area in cool water.
Correct3
Check for a patent airway, breathing, and circulation.
4
Cover the burned area with a clean, cool, tap water-dampened towel.
The first step in the management of a person who has sustained thermal injuries on 10% or more of his or her body surface is to assess the airway, breathing, and circulation. If the injury is less than 10% of total body surface area, then it would be appropriate to cover the burned area with a clean, cool, damp towel, but only after the airway, breathing, and circulation have been checked. It is not appropriate to cover the patient's afflicted area with ice because this can cause hypothermia and vasoconstriction, which would further reduce the blood flow to the injury site. Immersing the patient or the patient's afflicted area in cool water may cause extensive heat loss.
Text Reference - p. 455
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A patient with a burn inhalation injury is receiving albuterol (Ventolin) for bronchospasm. What is the most important adverse effect of this medication for the nurse to manage?
1
Gastrointestinal (GI) distress
Correct2
Tachycardia
3
Restlessness
Incorrect4
Hypokalemia
Albuterol stimulates β-adrenergic receptors in the lungs to cause bronchodilation. However, it is a noncardioselective agent so it also stimulates the β-receptors in the heart to increase the heart rate. Restlessness and GI upset may occur, but will decrease with use. Hypokalemia does not occur with albuterol.
Text Reference - p. 459
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The nurse is providing education to a patient who is in the rehabilitation phase of burn recovery after burning the arm with scalding water. Which of these statements by the patient indicates a need for further instruction?
1
"If the area itches, I can apply a water-based moisturizer."
Correct2
"After a month, I will be able to go to the beach to get a tan."
3
"I will need to wear the pressure garment for 24 hours a day."
4
"I will continue the range-of-motion exercises on a regular schedule."
Burn patients must protect healed burn areas from direct sunlight for about three months to prevent hyperpigmentation and sunburn injury. They should always wear sunscreen when they are outside. Water-based moisturizers are appropriate for itching. Pressure garments and masks should never be worn over unhealed wounds and, once a wearing schedule has been established, are removed only for short periods while bathing. Pressure garments are worn up to 24 hours a day for as long as 12 to 18 months. The range-of-motion exercises are important to prevent contractures that may develop as new tissue shortens.
Text Reference - p. 469
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The patient in the emergent phase of a burn injury is being treated for pain. What medication should the nurse anticipate using for this patient?
1
Subcutaneous (SQ) tetanus toxoid
Correct2
Intravenous (IV) morphine sulfate
3
Intramuscular (IM) hydromorphone (Dilaudid)
Incorrect4
Oral (PO) oxycodone and acetaminophen (Percocet)
IV medications are used for burn injuries in the emergent phase to deliver relief rapidly and prevent unpredictable absorption as would occur with the IM route. Tetanus toxoid may be administered, but not for pain. The PO route is not used because gastrointestinal function is slowed or impaired because of shock or paralytic ileus, although oxycodone and acetaminophen may be used later in the patient's recovery.
Text Reference - p. 463
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For a patient with chemical burn of 15% total body surface area (TBSA) on the legs, what kind of food should be encouraged?
1
High fat and high carbohydrate
Correct2
High protein and high carbohydrate
3
High protein and low carbohydrate
4
Low protein and low carbohydrate
The patient with chemical burn of 15% TBSA should be encouraged to eat a high-protein, high-carbohydrate diet. Foods high in protein and high in carbohydrates are important for tissue regeneration and promote wound healing. The daily estimated caloric needs should be calculated and regularly reassessed according to the patient's changing condition.
Text Reference - p. 467
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An 82-year-old patient is moving into an independent living facility. What is the best advice the nurse can give to the family to help prevent this patient from being accidently burned in the new home?
1
Cook for the patient
Incorrect2
Stop the patient from smoking
Correct3
Install tap water anti-scald devices
4
Be sure the patient uses an open space heater
Installing tap water antiscald devices will help prevent accidental scald burns that more easily occur in older people as their skin becomes drier and the dermis thinner. Cooking for the patient may be needed at times of illness or in the future, but the patient is moving to an independent living facility, so at this time should not need this assistance. Stopping the patient from smoking may be helpful to prevent burns, but may not be possible without the requirement by the facility. Using an open space heater would increase the patient's risk of being burned and would not be encouraged.
Text Reference - p. 451
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Why does the nurse apply enzymatic débriding agents to a patient with severe wounds?
1
To decrease blood loss
2
To remove the old microbial agent
3
To protect the reepithelializing keratinocytes
Correct4
To remove dead tissue from the healthy wound bed
Enzymatic débriding agents are made of natural products like collagen. Enzymatic débriding agents speed up the removal of dead tissue from the healthy wound bed. Skin grafting, a part of wound care, promotes massive blood loss in patients. To prevent this, topical application of epinephrine is advised. Washing the patient's wound with normal saline-moistened gauze removes the old antimicrobial agent. Paraffin gauze dressing protects the reepithelializing keratinocytes from damage. This dressing resurfaces and closes the open wound bed.

Test-Taking Tip: Have confidence in your initial response to an item because it more than likely is the correct answer.
Text Reference - p. 465
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A patient with severe inhalation burns has been receiving treatment for 24 hours. When assessing the patient, what findings would indicate respiratory distress? Select all that apply.
Correct 1
Restlessness
2
Increased sleep
Correct 3
Increased agitation
4
Increased water intake
Correct 5
Increased rate of breathing
Restlessness can result from respiratory distress, as the patient experiences disturbances in breathing. Increased agitation could result from the patient's attempts to compensate for an increasing oxygen demand and can be a sign of respiratory distress. An increased respiratory rate is a compensatory mechanism for the increased oxygen demands. It is a sign of impending respiratory distress and needs immediate attention. Increased sleep does not result from respiratory distress, as the patient becomes restless. Increased water intake is not specific to respiratory distress.

TEST-TAKING TIP: Look for answers that focus on the client or that are directed toward the client's feelings.
Text Reference - p. 459
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A patient arrives in the burn unit with erythema, pain, and mild swelling following a burn injury while cooking. Based on the wound observation and patient symptoms, the nurse should document the depth of the burn as what?
Correct1
First degree
2
Second degree
3
Third degree
4
Fourth degree
Burns which are painful, erythematous, and associated with mild swelling are first-degree burns. Second-degree burns are associated with vesicles and appear shiny. Third- and fourth-degree burns are white, waxy, and are insensitive to pain due to nerve destruction.
Text Reference - p. 454
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According to the Rule of Nines for calculating the percentage of burns, the nurse should assign what percentage to a burn in the genitalia?
Correct1
1%
2
4.5%
Incorrect3
9%
4
18%
The Rule of Nines is a formula used for calculating the percentage of burns during initial assessment of a burn patient. The genitals are assigned 1%. Burns in the head and arms are assigned 4.5% each. Burns on the lower extremities are assigned 9% each. Burns in the chest and back are assigned 18%.
Text Reference - p. 454
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A patient sustains a second-degree (partial-thickness) burn. Which layer(s) of skin does the nurse inspect for damage?
1
Epidermis only
2
Muscle and bone
Correct3
Epidermis and dermis
4
Epidermis, dermis, and subcutaneous tissue
In a second-degree or partial-thickness burn, both the epidermis and dermis are damaged. A first-degree superficial burn, such as sunburn, involves only the epidermis. A third- or fourth-degree full-thickness burn may involve muscle and bone. A third-degree deep partial- to full-thickness burn may include the epidermis, dermis, and subcutaneous tissue.
Text Reference - p. 453
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A patient is admitted to the burn center with burns of the face, upper chest, and hands after fireworks exploded in the patient's garage, catching the patient's shirt on fire. On assessment, the nurse notes that the patient is coughing up black sputum, has singed nasal hair, darkened oral and nasal membranes, and smoky breath with increasing shortness of breath and hoarseness. Which of these actions would be the most appropriate for the nurse to take next?
1
Insert a Foley catheter and monitor output.
Incorrect2
Obtain vital signs and a stat arterial blood gas (ABG).
3
Obtain a sputum specimen and send it to the lab stat.
Correct4
Anticipate the need for endotracheal intubation and notify the health care provider.
Inhalation injury results in exposure of the respiratory tract to intense heat or flames with inhalation of noxious chemicals, smoke, or carbon monoxide. The nurse should anticipate the need for endotracheal intubation and mechanical ventilation as this patient is demonstrating signs of severe respiratory distress. The nurse should also obtain vital signs and ABGs and insert a Foley, but these interventions are not a priority at this time. A sputum sample is not necessary at this time.
Text Reference - p. 456
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A nurse is caring for a patient with second- and third-degree burns to 50% of the body. The nurse prepares fluid resuscitation based on knowledge of the Parkland (Baxter) formula that includes which recommendation?
1
The total 24-hour fluid requirement should be administered in the first 8 hours.
Correct2
One half of the total 24-hour fluid requirement should be administered in the first 8 hours.
Incorrect3
One third of the total 24-hour fluid requirement should be administered in the first 4 hours.
4
One half of the total 24-hour fluid requirement should be administered in the first 4 hours.
Fluid resuscitation with the Parkland (Baxter) formula recommends that one half of the total fluid requirement should be administered in the first 8 hours, one quarter of total fluid requirement should be administered in the second 8 hours, and one quarter of total fluid requirement should be administered in the third 8 hours.
Text Reference - p. 460
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A nurse is teaching a patient's caregivers about the immediate action to be taken in case of burns of more than 10% of body surface area. What reasons does the nurse provide for avoiding the use of ice on the burned body part? Select all that apply.
Correct 1
Ice can cause hypothermia.
2
Ice can stop further tissue damage.
Correct 3
Ice can cause vasoconstriction.
Correct 4
Ice can reduce blood flow to the burned area.
5
Ice can increase the blood flow to the burned area.
Ice can cause hypothermia, resulting in excessive cooling of the burned part and reduction of blood flow to that area. Ice can also cause vasoconstriction, thus causing the blood vessels supplying the burned area to narrow and supply less blood and oxygen. Applying ice does not prevent further tissue damage; instead, it decreases the blood supply, causing delayed wound healing. Ice does not increase the blood flow to the burned area; rather it decreases the blood flow due to vasoconstriction.
Text Reference - p. 455
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A patient presents in the emergency department (ED) with burns on the hands and face after handling hydrochloric acid at work. What actions should the nurse perform toward the patient's burn management? Select all that apply.
1
Apply ice to the burned area.
2
Never wash the burn with water.
Correct 3
Remove all chemical particles on skin.
Correct 4
Remove all clothing containing the chemical.
Correct 5
Flush affected area with lots of water.
Remove all chemical particles on skin to remove the burn-causing agent from the patient's body. Remove all clothing containing the chemical, as the burning process continues while the chemical is in contact with the skin. Flush affected area with copious amounts of water to irrigate the skin from 20 minutes to 2 hours after chemical exposure to clear off the chemical on or around the affected area. Applying ice to the burned area does not help to wash away the chemical. Washing the burnt area with water helps to clean off the chemical.
Text Reference - p. 455
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The ambulance reports that it is transporting a patient to the emergency department who has experienced a full-thickness thermal burn from a grill. What manifestations should the nurse expect?
1
Severe pain, blisters, and blanching with pressure
2
Pain, minimal edema, and blanching with pressure
3
Redness, evidence of inhalation injury, and charred skin
Correct4
No pain, waxy white skin, and no blanching with pressure
With full-thickness burns, the nerves and vasculature in the dermis are destroyed so there is no pain, the tissue is dry and waxy looking or may be charred, and there is no blanching with pressure. Severe pain, blisters, and blanching occur with partial-thickness (deep, second-degree) burns. Pain, minimal edema, blanching, and redness occur with partial-thickness (superficial, first-degree) burns.
Text Reference - p. 454
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A patient is admitted to the burns ward with deep partial-thickness burns on the hands. What characteristics is the nurse likely to find when performing examination of the wound? Select all that apply.
1
Wounds are painless.
Correct 2
Wounds are wet and shiny.
Correct 3
Wounds are painful to touch.
Correct 4
Wounds appear pink to cherry-red.
5
Wounds appear black and leathery.
Partial-thickness wounds are wet and shiny due to serous exudates. These wounds are painful to touch due to nerve injury. Wounds appear pink to cherry-red. Wounds are painless in full-thickness burns due to nerve destruction. Wounds appear black and leathery in full-thickness burns, as all skin elements and local nerve endings are destroyed, and coagulation necrosis is present.
Text Reference - p. 455
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A patient is brought to the emergency department (ED) with partial-thickness burns on the hands and chest caused by a fire at the patient's house. What appropriate actions should the nurse perform to provide appropriate burn management for this patient? Select all that apply.
Correct 1
Assess for inhalation injury.
Correct 2
Provide 100% humidified oxygen.
Incorrect 3
Avoid dry dressings on the wounds.
Correct 4
Assess airway, breathing, and circulation.
5
Avoid mechanical ventilation for 24 hours.
The patient should be assessed for inhalation injury. Because these burns are caused by a fire, there is a high likelihood that the patient might have inhaled fumes. After assessing the airway, the nurse should provide 100% humidified oxygen to ensure adequate ventilation. The nurse should assess the patency of the airway as well as respirations and plan for the need for intubation accordingly. Dry dressings on the wounds may be applied to cover the wounds, if required. Mechanical ventilation may be required in case of significant inhalation injury.

TEST-TAKING TIP: Do not select answers that contain exceptions to the general rule, controversial material, or degrading responses.
Text Reference - p. 456
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Which precautions should the nurse take when changing a burn wound dressing? Select all that apply.
Incorrect 1
Use sterile gloves when removing a contaminated dressing.
Correct 2
Use sterile gloves when applying ointments and sterile dressings.
3
Keep the room cool to decrease the burning sensation of the wound.
Correct 4
Wear nonsterile, disposable gloves when washing the dirty wound.
Correct 5
Always wear personal protective equipment, such as masks, gowns, and gloves.
The nurse should use sterile gloves when applying ointment and sterile dressings. Nonsterile, disposable gloves should be worn when removing contaminated dressings and washing a dirty wound. The nurse should always wear personal protective equipment before the burn wounds are exposed. The room should be kept warm to prevent shivering in the patient.
Text Reference - p. 461
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The nurse is caring for a patient with superficial partial-thickness burns of the face sustained within the last 12 hours. Upon assessment the nurse would expect to find which manifestation?
Incorrect1
Blisters
Correct2
Reddening of the skin
3
Destruction of all skin layers
4
Damage to sebaceous glands
The clinical appearance of superficial partial-thickness burns includes erythema, blanching with pressure, and pain and minimal swelling with no vesicles or blistering during the first 24 hours.
Text Reference - p. 454
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A nurse is attending to a patient who has sustained full-thickness burns covering more than 20% of total body surface area (TBSA). Which initial interventions should the nurse perform as a part of emergency burn management? Select all that apply.
Correct 1
Begin fluid replacement.
2
Avoid supplemental oxygen.
Correct 3
Cover burned areas with dry dressings.
4
Lower the burned limbs below heart level.
Correct 5
Establish IV access with two large-bore catheters.
Begin fluid replacement to compensate for fluid loss. Cover the burned areas with dry dressings to begin the healing process and thus prevent contamination. An intravenous access should be established with two large-bore catheters to enable large amounts of fluid replacements. Supplemental oxygen is required to maintain adequate perfusion. The injured limb should be kept elevated above the heart level to prevent and decrease swelling.
...
A nurse is attending to a patient with extensive burns. What prophylactic treatment should the nurse plan to prevent a Curling's ulcer in this patient? Select all that apply.
Correct 1
Antacids
2
Antidiarrheal
Correct 3
H2-histamine blockers
Correct 4
Proton pump inhibitors
5
Calcium channel blockers
Antacids are used prophylactically to neutralize the acids present in the stomach. H2-histamine blockers (e.g. ranitidine [Zantac]) are used to inhibit histamine, which causes increase in acid levels. Proton pump inhibitors (e.g. esomeprazole [Nexium]) help to inhibit the secretion of hydrochloric acid, which increases as a stress response to the decreased blood flow to the gastrointestinal tract after burns. Antidiarrheal is useful in providing symptomatic relief for diarrhea. It cannot prevent a Curling's ulcer. Calcium channel blockers have no effect on protecting the gastrointestinal tract or on preventing development of Curling's ulcers.
Text Reference - p. 465
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A patient is brought to the emergency department (ED) following an inhalation injury. The patient has sustained burns on the face, neck, and chest due to a fire in the home. Which would help to confirm the diagnosis of upper airway injury? Select all that apply.
Incorrect 1
Dyspnea
Incorrect 2
Wheezing
Correct 3
Hoarseness
Correct 4
Singed nasal hair
Correct 5
Difficulty in swallowing
Upper airway injury may be caused by thermal burns or the inhalation of hot air, steam, or smoke. Hoarseness occurs due to laryngeal edema. Singed nasal hair is an obvious sign of inhalation of burned particles or smoke. Difficulty in swallowing is present due to edema and blistering of the oropharynx. Dyspnea can be observed where there has been an inhalation injury to the lower airway that is caused by breathing toxic chemicals or smoke that affects the trachea, bronchioles, and alveoli. Wheezing is a symptom found in an inhalation injury affecting the lower airway.
Text Reference - p. 452
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A nurse is caring for a patient who has sustained burns over the entire surfaces of both arms, the anterior trunk, and the right leg. The nurse uses the rule of nines to estimate the percentage of the burn surface area as:
Incorrect1
27%
2
36%
Correct3
54%
4
72%
The "rule of nines" is a method used to determine the body surface area (BSA) of a burn injury. It assigns 9% to each arm, 9% to the head, 18% to the anterior torso, 18% to the posterior torso, 18% to each leg, and 1% to the genitals. The other answer options are incorrect applications of the rule of nines BSA estimate.
Text Reference - p. 454
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A patient is admitted with second- and third-degree burns covering the face, entire right upper extremity, and the right anterior trunk area. Using the rule of nines, what should the nurse calculate the extent of these burns as being?
1
18%
Correct2
22.5%
3
27%
Incorrect4
36%
Using the rule of nines , for these second- and third-degree burns, the face encompasses 4.5% of the body area, the entire right arm encompasses 9% of the body area, and the entire anterior trunk encompasses 18% of the body area. Because the patient has burns on only the right side of the anterior trunk, the nurse would assess that burn as encompassing half of the 18%, or 9%. Therefore adding the three areas together (4.5 + 9 + 9), the nurse would correctly calculate the extent of this patient's burns to cover approximately 22.5% of the total body surface area. Eighteen percent, 27%, and 36% are incorrect calculations.
Text Reference - p. 454
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A patient is recovering from second- and third-degree burns over 30% of the body and is now ready for discharge. Just before leaving, the patient states, "What's going to happen to me? Will I ever look normal again?" The nurse recognizes that this patient is exhibiting which emotional response to the patient's type of injury?
1
Fear
2
Guilt
Correct3
Anxiety
4
Depression
Recovery from a 30% total body surface area (TBSA) burn injury takes time and is exhausting, both physically and emotionally for the patient. The health care team may think that a patient is ready for discharge, but the patient may not have any idea that discharge is being contemplated in the near future. Patients are often very fearful about how they will manage at home. While fear, anger, guilt, and depression are all common emotions experienced by a burn patient, this patient's statements reflect feelings of anxiety.
Text Reference - p. 469
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Fluid resuscitation is an important intervention in burn patients. The nurse recognizes that what fluid is recommended for the first 24 hours after a burn?
1
1 to 2 mL lactated Ringer's/kg/%TBSA burned
Correct2
2 to 4 mL lactated Ringer's/kg/%TBSA burned
Incorrect3
6 to 8 mL lactated Ringer's/kg/%TBSA burned
4
8 to 10 mL lactated Ringer's/kg/%TBSA burned
Fluid resuscitation is an important intervention in burn management. It helps to replenish the fluid loss caused by burns and maintain the fluid and electrolyte balance. The fluid recommendation for the first 24 hours is 2-4 mL lactated Ringer's/kg/%TBSA burned. A fluid volume of 1-2 mL lactated Ringer's/kg/%TBSA burned would be inadequate to meet the patient's requirement. Volumes of 6-8 mL lactated Ringer's/kg/%TBSA burned and 8-10 mL lactated Ringer's/kg/%TBSA burned may cause fluid overload.
Text Reference - p. 460
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While teaching care guidelines to a family member of a patient with burns, the nurse instructs the family member to include foods rich in omega-3 fatty acids in the patient's diet. What is the rationale behind the nurse's instruction?
1
To improve sleep
Correct2
To prevent blood clots
3
To promote weight gain
4
To decrease stomach acid
A patient with severe burns is at greater risk of venous thromboembolism. Omega-3 fatty acids are natural anticoagulants that decrease platelet aggregation. Eating foods rich in tryptophan, not omega-3 fatty acids, improves the patient's sleeping pattern. Tryptophan is an amino acid that blocks body wakeup cycles and promotes sleep. Foods rich in protein and fats, like peanut butter and red meat, help the patient gain weight. Avoiding spicy foods and drinking plenty of pure water helps decrease stomach acid.

Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer.
Text Reference - p. 463
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A burn patient has not received any active tetanua immunization within the previous 12 years. What is the primary nursing measure to help prevent the development of tetanus in the patient?
1
Administer tetanus toxoid
Incorrect2
Provide musculoskeletal relaxants
3
Provide 100% oxygen to the patient
Correct4
Administer tetanus immunoglobulin
Since the patient has not received any active immunization in the past 12 years, tetanus immunoglobulin administration is the primary measure. It would help in preventing development of tetanus. Tetanus toxoid administration would have been the primary measure if the patient had received active immunization within the past 10 years. Providing 100% oxygen does not ensure aerobic conditions at the burn area. Musculoskeletal relaxants will be helpful only after the patient develops tetanus.
Text Reference - p. 462
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A patient sustains burns covering 35% of the body surface area. The patient weighs 100 kg. Which action is most appropriate for the nurse to take during the early course of the patient's care?
Incorrect1
Administering 3500 mL of colloid IV fluids over the 8 hours after injury
2
Administering 140 mL/hr of colloid IV fluids for the 24 hours after injury
Correct3
Administering 7000 mL of crystalloid IV fluids over the 8 hours after injury
4
Administering 14,000 mL of crystalloid IV fluids over the 12 hours after injury
Crystalloid solutions, such as Ringer's lactate, are indicated for use in the initial IV fluid therapy for a burn patient. IV fluids for the first 24 hours may be calculated with the use of the Parkland formula based on body surface area (BSA), 4 mL/kg × BSA; therefore (4 mL × 100 kg) × 35 = 14,000 mL. The Parkland formula calls for half of the total fluids to be given over the first 8 hours, with the remaining given over the next 16 hours. Therefore the IV fluid prescription would be 7000 mL over 8 hours and 7000 mL over the next 16 hours. Administering 3500 mL of colloid IV fluids over the first 8 hours or 140 mL/hr of colloid IV fluids for 24 hours is incorrect because the volumes are incorrect and colloid fluids are not used during the fluid resuscitation period for burns (first 24 hours).
Text Reference - p. 460
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A patient is admitted to the burn unit with second-degree thermal burns. Which characteristics of a second-degree thermal burn should the nurse expect to find during the physical assessment? Select all that apply.
Correct 1
Fluid-filled vesicles
Correct 2
Severe pain
Correct 3
Mild edema
4
Waxy, white, hard skin
Incorrect 5
Visible thrombosed vessels
Second-degree burns show epidermal and dermal involvement to varying depths. These burn injuries are characterized by fluid-filled vesicles that are erythematous, glossy, and damp. The patient may complain of severe pain caused by nerve injury. Mild to moderate edema may be present. Waxy, white, hard skin and visible thrombosed vessels are found in third-degree burns.

TEST-TAKING TIP: Do not spend too much time on one question, because it can compromise your overall performance. There is no deduction for incorrect answers, so you are not penalized for guessing. You cannot leave an answer blank; therefore, guess. Go for it! Remember: You do not have to get all the questions correct to pass.
Text Reference - p. 454
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A nurse working in a burn unit identifies that which patients are at an increased risk of developing venous thromboembolism? Select all that apply.
1
Young age
Correct 2
Morbid obesity
Correct 3
Prolonged immobility
4
Upper-extremity burns
5
First-degree burn of a finger
The risk factors for the development of venous thromboembolism a burn patient are morbid obesity and prolonged immobility. These patients may develop stasis of blood due to immobility, which results in development of venous thromboembolism. Young age is not a risk factor for venous thromboembolism; rather, old age predisposes a person to venous thromboembolism. Usually lower-extremity burns are risk factors for venous thromboembolism as they cause stagnation of blood. First-degree burn of a finger is not an extensive burn and hence not a risk factor for venous thromboembolism.
Text Reference - p. 459
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In caring for a patient with burns to the back, the nurse knows that the patient is moving out of the emergent phase of burn injury when what happens?
Incorrect1
Serum sodium and potassium increase
2
Serum sodium and potassium decrease
3
Edema and arterial blood gases improve
Correct4
Diuresis occurs and hematocrit decreases
In the emergent phase, the immediate, life-threatening problems from the burn, hypovolemic shock and edema, are treated and resolved. Toward the end of the emergent phase, fluid loss and edema formation end. Interstitial fluid returns to the vascular space and diuresis occurs. Urinary output is the most commonly used parameter to assess the adequacy of fluid resuscitation. The hemolysis of red blood cells (RBCs) and thrombosis of burned capillaries also decreases circulating RBCs. When the fluid balance has been restored, dilution causes the hematocrit levels to drop. Initially sodium moves to the interstitial spaces and remains there until edema formation ceases, so sodium levels increase at the end of the emergent phase as the sodium moves back to the vasculature. Initially potassium level increases as it is released from injured cells and hemolyzed RBCs, so potassium levels decrease at the end of the emergent phase when fluid levels normalize.
Text Reference - p. 455
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A nurse is attending to a patient with partial-thickness burns on the face, including corneal burns. What should she do to protect the eyes of the patient? Select all that apply.
Correct 1
Use antibiotic ointments.
2
Wait for laboratory reports.
Correct 3
Arrange for ophthalmology examination.
Correct 4
Instill methylcellulose eye drops.
5
Inform the patient that periorbital edema is serious.
Eye care for corneal burns or edema includes antibiotic ointments. An ophthalmology examination should be conducted on all patients who have sustained facial burns. The use of methylcellulose drops or artificial tears is recommended for moisture and additional comfort. Waiting for laboratory reports does not help the patient; rather, the nurse can start the basic examination and treatment in the process mentioned above. Avoid giving any misleading information, such as telling the patient that periorbital edema is serious. This can frighten the patient and prevent eye opening. The nurse should assure the patient that the swelling is not permanent.

TEST-TAKING TIP: Answer every question. A question without an answer is always a wrong answer, so go ahead and guess.
Text Reference - p. 462
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When caring for a patient with an electrical burn injury, which prescription from the health care provider should the nurse question?
Incorrect1
Mannitol 75 gm intravenous (IV)
2
Urine for myoglobulin
Correct3
Lactated Ringer's at 25 mL/hr
4
Sodium bicarbonate 24 mEq every four hours
Electrical injury puts the patient at risk for myoglobinuria, which can lead to acute renal tubular necrosis (ATN). Treatment consists of infusing lactated Ringer's at 2--4 mL/kg/% total body surface area (TBSA), a rate sufficient to maintain urinary output at 75 to 100 mL/hr. An infusion rate of 25 mL/hr is not sufficient to maintain adequate urine output in prevention and treatment of ATN. Mannitol also can be used to maintain urine output. The urine would be monitored also for the presence of myoglobin. Sodium bicarbonate may be given to alkalinize the urine.
Text Reference - p. 460
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A patient has 20% total body surface area (TBSA) burns from a brush fire. For the past week, the patient's wounds have been debrided and covered with a silver-impregnated dressing. Today the nurse noticed that the partial-thickness burn wounds have been fully debrided. The nurse's priority intervention for wound care at this time would be to
Incorrect1
Reapply a new dressing without disturbing the wound bed
Correct2
Apply fine-meshed petroleum gauze to the debrided areas
3
Wash the wound aggressively with sterile saline three times a day
4
Apply cool compresses for pain relief in between dressing changes
When the partial-thickness burn wounds have been fully debrided, a protective, coarse or fine-meshed, greasy-based (paraffin or petroleum) gauze dressing is applied to protect the re-epithelializing keratinocytes as they resurface and close the open wound bed. The nurse would not wash the wound aggressively with saline three times daily, apply cool compresses, or apply a new dressing at this time.
Text Reference - p. 461
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The nurse collaborates with the health care team regarding the treatment of partial-thickness second-degree burn to the chest, abdomen, and both anterior thighs sustained by a patient. Which treatment does the nurse recognize as appropriate and within the scope of nursing practice?
1
Application of autografts and daily sterile dressing changes
2
Twice-weekly wound cleaning and sterile dressing changes
Correct3
Daily wound cleaning with debridement and sterile dressing changes
4
Daily wound cleaning with hydrotherapy and clean dressing changes
Daily wound cleansing with debridement and sterile dressing changes is appropriate care for a major burn wound. As a means of promoting healing and prevent infection, wound care and dressing changes are performed once or twice a day with a sterile procedure. The other answer options are not within the scope of nursing practice and may not be appropriate treatment for the burn injury sustained.
Text Reference - p. 461
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The nurse recalls which description as the most accurate regarding a deep partial-thickness burn?
Correct1
Painful with weeping blisters
2
Minimal damage to the epidermis
Incorrect3
Charring visible in the deepest areas
4
Necrotic tissue through all layers of the skin
A deep partial-thickness burn involves the epidermal and dermal layers of the skin. It is characterized by a wet, shiny, weeping surface marked by blisters and is painful and very sensitive to the touch. Necrosis and charring are seen with a full-thickness burn. Redness and pain with minimal damage to the epidermis are characteristics of a superficial, or first-degree, burn.
Text Reference - p. 453
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A nurse is attending to a patient with partial-thickness burns on the hands and legs. What actions should the nurse perform as a part of the wound care for the emergent phase of treatment? Select all that apply.
Correct 1
Administer a tetanus antitoxin.
Incorrect 2
Avoid using topical antibiotics.
3
Avoid using antimicrobial dressings.
Correct 4
Assess the extent and depth of the burns.
Correct 5
Perform debridement as required.
The burn management involves emergent phase, acute phase, and rehabilitation phase. The emergent phase involves early management of the burns patient and includes airway management, and fluid and wound therapy. Tetanus antitoxin should be administered to prevent sepsis. Assessment of extent and depth of burns should be done to determine the severity of burns, plan burns management, and consider referring to a burn center. Debridement should be performed as required to keep the wound clean, remove any chemical causing the burn, or to prevent further tissue damage. Use of topical antibiotics and antimicrobial dressings are not of prime importance in the emergent phase; they are usually used in the acute and rehabilitation phases.
Text Reference - p. 460
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A patient with partial-thickness burns is now allowed oral feedings. What nursing interventions should the nurse perform to maintain the patient's nutrition? Select all that apply.
Correct 1
Ask caregivers to get the patient's favorite food.
2
Suggest low-calorie food.
Correct 3
Suggest a high-protein diet.
4
Suggest reduced fluid intake.
Correct 5
Suggest a high-carbohydrate diet
The patient may have a reduced appetite and may not like the food from the hospital. Therefore, the caregivers can get the patient's favorite food. A swallowing assessment should be done by a speech pathologist before beginning with oral feeds. The patient should be provided with a high-protein diet to promote tissue healing and avoid malnutrition. A high-carbohydrate diet should be provided to meet the high metabolic demands. A low-calorie food may not meet the calorie requirements of the patient and leads to malnutrition and delayed wound healing. An adequate intake of fluids is essential for healing.

TEST-TAKING TIP: Make certain that the answer you select is reasonable and obtainable under ordinary circumstances and that the action can be carried out in the given situation.
Text Reference - p. 467
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A patient is suspected to have a smoke inhalation burn and carboxyhemoglobinemia. In what order should the nurse perform the treatment interventions?
Incorrect
1.
Check for the adequacy of ventilation.
Incorrect
2.
Check for a patent airway and soot around nares and tongue.
Correct
3.
Check for the patient's pulse.
Correct
4.
Elevate any burned limbs above the heart to decrease pain and swelling.
The most important intervention is to check that the airway is patent. Then evaluate the adequacy of appropriate ventilation, followed by a check of the patient's pulse. Finally, elevate any burned limbs above the heart to decrease pain and swelling.
Text Reference - p. 455
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A patient arrives at the burn unit with large burns on the chest and abdomen. While assessing the patient, the nurse suspects full-thickness burns. What findings are likely to be found in the patient with full-thickness burns? Select all that apply.
Correct 1
The patient has low blood pressure.
Correct 2
The patient is shivering.
3
The burned areas have blisters.
4
The burned areas are very painful.
Correct 5
The patient has absence of bowel sounds.
The patient with severe burns is likely to be in shock from hypovolemia and may have low blood pressure. The patient experiences shivering as a result of chilling that is caused either by heat loss, anxiety, or pain. The patient with a larger burn area may develop a paralytic ileus, which may be accompanied with absent or decreased bowel sounds. The burned areas have blisters filled with fluid and protein in cases of partial-thickness burns. Superficial to moderate partial-thickness burns are very painful.
Text Reference - p. 458
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While planning physical therapy for a patient suffering from burns, which should be included? Select all that apply.
1
Practice physical therapy only occasionally.
Incorrect 2
Perform exercises before wound cleansing.
Correct 3
Perform passive and active ROM on all joints.
4
Provide pillows to sleep for patients with neck burns.
Correct 5
Perform exercises during and after wound cleansing.
Perform passive and active ROM on all joints to avoid contractures and prevent compromising on patient's cardiopulmonary status. It is not a good habit to practice physical therapy only occasionally. This is because continuous physical therapy throughout burn recovery is imperative if the patient needs to regain and maintain muscle strength and optimal joint function. A good time for exercise is during and after wound cleansing, when the skin is softer and bulky dressings are removed. Performing exercises before wound cleansing is not appropriate. Patients with neck burns should continue to sleep without pillows or with the head hanging slightly over the top of the mattress to encourage hyperextension and avoid contractures.

TEST-TAKING TIP: Relax during the last hour before an exam. Your brain needs some recovery time to function effectively.
Text Reference - p. 467
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A patient with partial-thickness burns is being treated with zolpidem (Ambien). What is the appropriate nursing response to the patient's caregivers when they ask about the purpose of administering this drug? Select all that apply.
Correct 1
To promote sleep
Correct 2
To reduce anxiety
3
To promote wound healing
4
To prevent thromboembolism
Correct 5
To provide short-term amnesic effects
Zolpidem is a sedative-hypnotic medicine and is given to patients suffering from burns. Zolpidem promotes sleep, reduces anxiety, and provides short-term amnesic effects. Nutritional support is used to promote wound healing. Anticoagulants are used to prevent thromboembolism.
Text Reference - p. 463
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A patient is brought to the emergency department (ED) with a history of inhalation injury from hot air in a manufacturing unit. The patient has also sustained burns on his face, neck, and hands. What actions should the nurse perform immediately? Select all that apply.
Correct 1
Check for evidence of inhalation of smoke.
2
Observe for the next 2 hours.
3
Wait for laboratory reports.
Correct 4
Observe for signs of respiratory distress.
Correct 5
Perform early endotracheal intubation.
Checking for smoke inhalation is an important step to evaluate burn victims. Also, looking out for signs of respiratory distress like increased agitation, anxiety, restlessness, or a change in the rate or character of breathing is important. Early treatment includes airway management that involves early endotracheal (preferably orotracheal) intubation, as it eliminates the need for an emergency tracheostomy. Observing the patient for the next 2 hours does not help because treatment must begin at the earliest possible moment. In general, the patient suffering from burns on the face and neck may have mechanical obstruction caused by massive swelling of the tissues and requires intubation within 1 to 2 hours after the injury.
Text Reference - p. 455
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A nurse is planning care for a patient with a 30% body surface area burn injury. Which statement regarding the nutritional status of this patient is true?
1
Decreased protein intake will decrease the chance of renal complications.
2
Maintaining a hypermetabolic state reduces the patient's risk for infection.
3
Controlling the temperature of the environment reduces caloric requirements.
Correct4
A hypermetabolic state results in poor healing and increased protein and lipid needs.
A burn injury causes a hypermetabolic state, resulting in protein and lipid catabolism that can inhibit wound healing. Therefore the patient with a burn injury requires increased calories and protein to enable the healing process. Protein intake in the burn patient should be increased to promote wound healing. Renal function is monitored for complications, which is low risk with burns, because the need for protein is increased. A hypermetabolic state is not desired and is a complication of a burn injury. Controlling the temperature of the environment has no effect on caloric requirements.
Text Reference - p. 463
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A nurse is involved in the wound care of patients on the burn management unit. What precautions should the nurse take while performing wound care?
Correct 1
The nurse wears personal protective equipment.
2
The nurse wears the same gown and masks for all patients.
3
The nurse uses nonsterile gloves when applying ointments.
Correct 4
The nurse uses sterile gloves when applying sterile dressings.
Correct 5
The nurse uses nonsterile gloves when removing contaminated dressings.
The nurse wears personal protective equipment like a disposable gown, mask, and gloves to prevent the spread of infection. The nurse uses sterile gloves when applying sterile dressings to prevent infection. The nurse uses nonsterile gloves when removing contaminated dressings for self-protection. The nurse should not wear the same gown and masks for all patients to avoid cross-contamination. It is necessary to wear new equipment before treating a new patient. The nurse should not use nonsterile gloves when applying ointments. Since the wound is open, sterile gloves should be used to prevent contamination.

TEST-TAKING TIP: Do not select answers that contain exceptions to the general rule, controversial material, or responses that appear to be degrading.
Text Reference - p. 461
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A patient is being treated for burns on the face and ears due to a fire at home. What precautions should the nurse take to protect the ears from damage? Select all that apply.
Correct 1
Keep ears free from pressure.
Correct 2
Avoid using pillows.
3
Apply a heavy gauze dressing for fast healing.
Incorrect 4
Wrap ears with sterile gauze after applying ointment.
Correct 5
Elevate patient's head by placing rolled towel under shoulders.
Ears should be kept free from pressure because of their poor vascularization and tendency to become infected. Avoid using pillows, as the pressure on ear cartilage may cause chondritis, and the ear may adhere to the pillowcase, causing pain and bleeding. The patient's head is elevated by placing a rolled towel under shoulders to reduce pressure over the ears. It helps to prevent pressure necrosis. A heavy gauze dressing should not be applied, as it can put pressure on the ears and damage them. Ears are not to be wrapped with sterile gauze after applying ointment in order to avoid pressure over the ears.
Text Reference - p. 462
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During the care of the patient with a burn in the acute phase, which new interventions should the nurse expect to do after the patient progresses from the emergent phase?
1
Begin intravenous (IV) fluid replacement
Correct2
Monitor for signs of complications
Incorrect3
Assess and manage pain and anxiety
4
Discuss possible reconstructive surgery
Monitoring for complications (e.g., wound infection, pneumonia, contractures) is needed in the acute phase. Fluid replacement occurs in the emergent phase. Assessing and managing pain and anxiety occurs in the emergent and the acute phases. Discussing possible reconstructive surgeries is done in the rehabilitation phase.
Text Reference - p. 464
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A patient has thermal burns on his face, including the cheeks and the area around the eyes. Which measures should the nurse take?
Incorrect1
Instill artificial tears in each eye.
2
Wrap sterile gauze around his face.
Correct3
Cover his face with silver sulfadiazine ointment and gauze.
4
Apply silver sulfadiazine ointment only without the use of gauze.
The face is highly vascular and may become edematous after a thermal burn. It should be covered with ointment and gauze to prevent vascularization and swelling. Wrapping gauze around the face will create pressure on delicate facial structures. The gauze is required to cover the face after the application of silver sulfadiazine ointments to prevent infection. Artificial tears or methylcellulose drops are used to treat eyes after a burn.
Text Reference - p. 462
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While assessing a patient with severe burns, the nurse suspects hypokalemia. What possible causes should the nurse evaluate? Select all that apply.
Correct 1
Vomiting
Incorrect 2
Renal failure
Correct 3
Prolonged gastrointestinal (GI) suction
4
Adrenal insufficiency
Correct 5
IV therapy without potassium
Hypokalemia occurs due to lack of potassium. Excessive vomiting causes loss of body fluids leading to a loss of potassium. Prolonged GI suction also causes fluid loss and decreases potassium levels. The IV therapy without potassium fails to compensate for the loss of potassium, and the deficiency persists, thus resulting in hypokalemia. Renal failure and adrenal insufficiency are the causes of hyperkalemia, which is marked by an increase in potassium levels.
Text Reference - p. 464
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